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Theses and Dissertations

4-18-1995

Comorbidity of attention deficit hyperactivity disorder and Comorbidity of attention deficit hyperactivity disorder and

educational classification among in-patient populations of educational classification among in-patient populations of

children and adolescents children and adolescents

Holly Berezow-Ricker Rowan College of New Jersey

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COMORBIDITY OF ATTENTION DEFICIT HYPERACTIVITY

DISORDER AND EDUCATIONAL CLASSIFICATION

AMONG IN-PATIENT POPULATIONS

OF CHILDREN AND ADOLESCENTS

byHolly Berezow-Ricker

A Thesis

Submitted in partial fulfillment of the requirements of theMaster of Arts Deree in the Graduate Division

of Rowan CollegeApril 18, 1995

Approved byPToressor

Date Approved

ABSTRACT

Holly Berezow Ricker

COMORBIDITY OF ADHD AND EDUCATIONAL CLASSIFICATIONAMONG IN-PATIENT POPULATIONS OF CHILDREN AND ADOLESCENTS

1995Dr. Roberta Dihoff

Masters of School Psychology

This thesis is an ex post facto study of an in-patient population of 39 adolescents

between the ages of twelve and eighteen at a New Jersey State Psychiatric Hospital for

Adolescents and 74 pre-adolescents and adolescents between the ages of seven and

fifteen at a Pnvate Residential School in New Jersey . Of this population of N-=13.

n=48 were detennined to have Attention Deficit Hyperactivity Disorder (ADHD) with an

incidence rate of 42.5%. Significant co-morbidity of ADHD and Depression, Conduct

Disorder/Oppositional Defiant Disorder. Psychotic Disorders, and Learning Disabilities

were found. The incidence of co-morbidity of ADHD and Educational Classification

was found to be significantly higher than the incidence researched among more diverse

population groups as represented by the New Zealand (Anderson et. al, 1985) and Puerto

Rico (Bird et. al., 1988) large population surveys. The ranked correlation's between

ADHD and Educational Classification was found to be r= 985 (P> .01), and between

ADHD, Classification and Other Behavioral Disorders was found to be r=.854 (P> 01)

This procedure supports the premise of utilizing Child Study Teams to provide data to

plan globally and programmatically as well as to prepare individual education plans.

MINI ABSTRACT

Holly Berezow Ricker

COMORRIDITY OF ADHO AND EDUCATIONAL CLASSIFICATIONAMONG IN-PATIENT POPULATIONS OF CHILDREN AND ADOLESCENTS

1995Dr. Roberta Dihoff

Masters of School Psychology

ATn ¢ fpoCtfacto study of N= 13 children (aged 7-18) placed at a State Mental

Hospital or Private Residential School Via hypothesis testing and ranked correlation's,

n=48 (42.5%) showed significant (P>.0 1) comorbidity of Attention Deficit Hyperactivity

Disorder with Learning Disabilities (r-.985) and/or Depression, Conduct

Disorder/OppositionaI Defiant Disorder, Psychotic Disorder (r=854).

ACKNOWLEDGMENTS

Special thanks in creaton of this thesis go to my research assistants at both

facilities; Donna Galarza at the New Jersey State Psychiatric Hospital for

Adolescents and Marie Adams at the Private Residential School for Boys without

whom there would be no possibility of ex postfacto study Gratitude also goes to

my professors and advisors, Dr. John Klanderman and Dr. Roberta Dihoff. with a

special mention to Dr. Greg Potter, for their tireless technical assistance, support

and optimism that research projects do, in fact get completed Lastly, a loving

honorable mention goes to my husband and children, Raymond, Stewart and Ahren

Ricker, without whom there would be no affective purpose to my pursuit of higher

education

"Knowledgeyeilds the highest-quality power."

(Toeffler, 1990, p. 468.)

TABLE OF CONTENTS

Chapter Page

Chapter I .................... . .. ........ ii....&W........................ . IChapter II...................................... .................................................. 25

Chapter II ............................................................................................... 47

Chapter TV .............................................................--.......... 51

Chapter V ......................................................................... ......... 62

Referene ............... ....... ....... ................................... 75

Index of Tables and Figures ................................................................ 79

Appendix A: Figures

Appendix B: Data

I

CHAPTER 1: THE PROBLEM

NEED:

Like the Nature vs. Nurture debate, Comorbidity of Attention Deficit

llyperactivity Disorder (ADHD) with the other Disruptive Behavor Disorders, such

as Conduct Disorder (CD) and Oppositional Defiant Disorder (ODD), as well as with

Depression, has long been an issue of philosophical dissension in the psychological

and psychiatric diagnostic community is there, demonstrably, a separate category of

ADHD + CD/ODD or are the defined behavioral difficulies symptoms of the same

disorder with differing levels of seventy or presentation (Fletcher, Morris & Francis,

1991). Similar concerns have been expressed regarding studies of ADIHD as

comorbid with Depressive Disorders Since the introduction of the Diagnosiric and

Statistical Manual (DSM-III-R), there is a reliable bellwether of clinical thought The

DSM-IIl-R and the DSM IV both define ADHD as a separate clinical condition

among the Disruptive Behavior Disorders (DSM -II-R, 1987, Barkley, 1993) The

diagnosis of ADD-Hyperactivity (Barkley, 1990) or 314.00, Undifferentiated

Attention-deficit Disorder (DSM-II1-R, 1987) has been discarded and will not be

considered in this study as comorbid with Depression

2

Recently, with these new definitions of ADHD, assumed rates of comorbidity

with other disorders have fallen. Conversely, rates of ADl-D r specific Learning

Disabilities (LD) have nsen as the definition of ADHD has been defined to exclude

symptoms of reading difficulties (Cantwell & Baker, 1991, Dykman & Ackerman,

1991, Shaywitz & Shavwitz, 1991). Elevated incidences of negative adolescent

outcomes, however, have remained fairly stable as has the comorbidity of Juvenile

Delinquency and Disruptive Behavior Disorders (Fischer, et.al., 1990, Hahn, 1987,

Moffitt, 1990). While there have been studies of rates of comorbidity in adolescent

populations with ADHD, and rarer studies with in-patient populations (Strober, et.a.,

19S8; Woolston, et. al., 1989), these have focused on rates of CD/ODD and/or

Depression in the families and individuals already diagnosed as having ADHD The

proposed study will review the incidence rates of ADI-ID in individuals already

diagnosed as having CD/ODD, Depression, or related Emotional Disturbance as

defined during their Educational Classifications. The population of in-patients will

be comparable to earlier in-patient studies where Strober evaluated 81 individuals,

Woolston 35 (Biedermar Newcorn & Sprich, 1991) and the proposed study will

examine between 40 and 60 individuals currently receiving in-patient treatment under

Class-B commitment to a New Jersey State Psychiatric Hospital for Adolescents as

well as 70 individuals residing at a private residential school for boys in New Jersey.

3

PURPOSE:

It is this author's contention that Child Study Services are chronically under

uiliied by educational administrations. Besides problems with the referral process,

the Child Study Teams are gatherers and repositories of vast amounts of data that

could be processed and used in a wide variety of administrative decision making.

This became clear in the Spring of 1993, when decision-makmg regarding Title XI,

Chapter 1 grant applications and classroom procedures became an issue at a New

Jersey State Psychiatric Hospital For Adolescents. In order to define the need for

Chapter 1 (as per the Individuals With Educational Disabilities Act T.W.E.D., PL 89-

313; and Elementary and Secondary Schools Improvement Act, E S S A, PL 100-

297) basic skills classrooms at the facilities' school an in-depth study of the students

was proposed Protocols were to be gaven to current students, teachers and

administrators were to be interviewed, classes would be observed m progress. The

facilities' Child Study Team mentioned that these evaluations were routinely

performed as a part of the Educational Classification process.

The Certified School Social Worker for the program in question had amassed

a database of between 30 to 40 pupils who had used the educational services during

the past year. Organization and analysis of this data revealed that approximately one

third of these students scored in the Below Average Poor or Vetr Poor range of

adaptive functioning on the Slossen Adaptive Behavior Inventory (Slossen. 1987)

and would benefit from basic and adaptive skills remediation. It is to be assumed

4

that Learning Disability Teacher/Consultant evaluations would provide similarly

specific information to determine curricular needs and that School Psychologist's

reports would yield information regarding performance potentials and ways these

potentials are effected by the medication rates and other behavioral factors relevant to

the therapeutic milieu.

It is hoped that this study will provide further insight into the nature of the

educational challenges of in-patient adolescent and pre-adolescent populations This

may enhance the hospital's ability to develop education plans, programs and

cumcular options for it's unrque student population. It may provide a model for

future feasibility or background studies by educational decision-makers using pre-

existing Child Study Team documents and pupil records. In the private school

setting, this study may lead to targeted in-services for the teachers and residential

staff

STATEMENT OF THEORY:

As early as 1964, in profiling the child with 2finmmal Brain Dysfunction,

clinical indicators were presented which m retrospect appear to be allusions to dual-

diagnosis or comorbidity The list of outstanding characteristics presented by Dr.

Clements (Clements, 1964) includes "specific learning deficits," "perceptual-motor

deficits," equivocal or soft neurological signs," and "borderline abnormal or

abnormal EEG" Much of the article deals with assessment of specific reading

S

disorders included at that time with hyperlanesls as a facet of Minimal Brain

Dysfunction, as well as mentiomng dyslexia and lability of mood.

By 1979, "...brain damage had been relegated to an extremely minor role as a

cause of the disorder (Barkley, 1990; p. 20),'" and in 1980 the DSM-II1 had a separate

and more clearly defined category of Attention Deficit Disorder with and without

Hyperactivity (Barkley, 1990). As diagnostic criteria were being refined and

responses to methylphemdate, stimulants and other drugs demonstrated a range of

behavior and mood disorders, differences between these syndromes were defined.

Much of the research on comorbidity of ADHD and other disorders dates from the

DSM-III and DSM-III-R (Biederman, Newcorn & Sprich, 1991).

A high incidence rate of comorbidity of ADHD and other behavioral and

cognitive disorders has long been accepted, "On one level, the large number of

children affected and the high degree of comorbidity clearly mandate intense efforts

to better understand the nature of the disorder (Shaywitz & Shaywitz, 1991, p. 69)."

But to what end are these diagnostic efforts headed? According to these authors, and

the ilnteragency Committee on Learnung Disabilities (1987), the goal is, "...the

development of a classification system that more clearly defines and diagnoses

learning disabilities, conduct disorders and attention deficit disorders, and the inter-

relationships (Shayvitz & Shaywitz, 199)1 '" This information would lead to

improved treatment and planning for the effected children "'Given the presence of

two or more diagnosable conditions, what are the sequential treatment foci? (Clarkin

& Kendall, 1992, p. 907)."

6

Why is clarification of comorbidiry with ADHD important other than

epidemiologically, and why focus on the adolescent and pre-adolescent population?

Hahn (1987) identified ten major nsk factors for dropping out of high school, five of

which directly effected the dually-diagnosed adolescent; behind in grade level and

older than classmates, poor academic performance. dislike school, detention and

suspension and undiagnosd learning disabilities and emotional problems. These nsk

factors effect pupils with comorbidity of ADHD and CD, AD-HD and ODD, AD-ID

and LD, ADI-ID and Depression, and related Juvenile Delinquency.

Most studies of comorbid populations focus upon clinically referred

populations of children diagnosed as ADHD who presented with related comorbid

symptomology but resided in community settings and participated in the studies on an

out-patient basis. Slgnificant rates of comorbidity were found, particularly in

populations already considered at risk such as Juvenile Delinquents (Moffitt, 1990),

comorbid neurological disorders (Fischer, et. al., 1990), comorbid mood disorders

(Barkley, et. al., 1992) and interrelated behavior disorders (Biedermani, Newoom &

Spnch, 1991). Even higher correlations vere found in the rare in-patient population

studies (Woolston, ct al 1989) These correlates all pointed towards risk of

negative adolescent outcomes and the search for effective and targeted treatment

programs continues.

The present study was conceived to approach the dilemma from an opposite

angle. The present adolescent and pre-adolescent populations have already

demonstrated negative outcomes, viz, psychiatric hospitalization under a c'Class B"'

7

commnitlment and/or residential placement ("most restrictive" educational program

placement) via the County Children's Assessment Resource Team (CART) process

They have already been diagnosed with related disorders other than ADHD This

study will detenmne the rate of comorbid ADHD in this population that has already

been classified as having a learning disability via educational classification, as well

as a behavior disorder or mood disorder as per psychiatric diagnosis Rates of

comorbid ADHD will be determined secondary to the outcome. It is expected that

the correlates between these disorders will be very lhgh and that they may

demonstrate a predictive quality that may lead to targeted treatment in an educational

setting. A discrete in-patient population of adolescents and pre adolescents with

ADHD + Educational Classificauon + Behavior or Mood Disorders may be identified

that may require unique interventions

HYPOTHESES:

Given the severity of symptomology required for a Class B commitment or a

"most restrictive" educational program placement via the CART process, it is

hypothesized that the study population will present with a measurably higher

incidence of ADHD then the general population. Further, it is proposed that the study

population will present with a significantly higher incidence of ADHD and

Educational Classification than a more diverse population educated in a variety of

settings identified via a literature review. Likewise, the rate ofcomorbidity of ADHD

8

and education classification should be signricantly higher in the study population

when compared to populations in less restrictive settings

The correlation between ADHD and educational classification in the inpatient

study group is hypothesized to be statistically significant and will be comparable to

correlations of comorbiditv found in earlier inpatient studies of ADIID populations

It is further hypothesized that there will be a statistically significant correlation

between the study group with ADHD + educational classification and other comorbid

behavioral problems such as CD, ODD and/or Depression.

I, The incidence of co-morbididty of ADHD and Classification among thein-patient adolescents and pre-adolescents will be higher than theincidence among more dverse population groups.

II, There will be a statistically stmficant correlation between ADHD andClassification in the in-patient adolescent and pre-adolescent population.

IIl. There will be a statistically significant correlation between ADID +Classification and other behavioral problems in the in-patient adolesecentand preadolescent population.

DEFINITIONS:

Wherever possible, definitons will be taken from the DSM-III-R, as

presumably any diagnoses found during records review will have been based upon the

DSM-III-R. Lists of Diagnostic Criteria for ADI-D, CD, Depressive Disorders, and

ODD will be found in Appendix A. Those aspects of NJAC 6:28 related to

Educational Classifications will also be included in Appendix A.

9

Adolescent:

Although Adolescence may be defined to correspond exactly with the

physiological stage of pubescence, for the purposes of this study it shall be defined as

per funding and program criteria for admission into adolescent treatment programs,

both 'm-patient and out-patient, in the state of New Jersey. Adolescent means an

individual between the ages of twelve years zero months ad their eighteenth birthday

who would be eligible, if necessary, for inclusion in a state or federally funded

program for adolescents.

Attention-Deficit Hyperactivity Disorder (ADHD):

ADHD children are commonly described as having chronic difficulties in the

areas of inatention, rmpulsrvity, and overactiviry - what one might call the

"holy trinity" of ADHD. They are believed to display these characreristics

early; to a degree that is inappropriate for their age or developmental level;

and across a variety of situations that tax their capacity to pay attention

inhibit their impulses, and restrain their movement (Barkley. 1990, p. 40).

In addition to the criteria as established in the DSM-III-R for ADHD (314.01),

Barkley considers the diagnostic criteria for Hyperkinetic Disorder from the

10

International Classification of Diseases, 10th Edition (Barkley, 1990) in compiling

his definition of ADHD. For the purposes of this study, any mention of chronic

problems with "inattention,' "impulsivity," or "overactivity/hyperactivity

ihyperkinesis" in the pupil's record as may have been defined using the Child

Behavior Checklist (CBCL, 1983), Adaptive Behavior Measures, Connor Scales, or

other objective or informal measures, or Case History, as in a mention of these

symptoms in an earlier report or protocol, or suggestion of ADHD in the evaluations

prepared by a certified child study team member (School Social Worker, School

Psychologist, Learning Disability Teacher Consultant), clinical staff member

(Psychologtst, Psychiatrist Psychiatric Social Worker), will be considered to define

the existence of AD-ID in the individual's clinical picture. AD-ID and

Undifferentiated ADD will be considered to be the same clinical grouping as per

revisions in the DSM-IV (Barkley, et. al. 1992).

It

Children's Assessment Resource Team (CART):

The CART process was established by the Bring the Children Home Act

(BCIIA, PL 1992-111) to reduce out of state placement of New Jersey resident

children as well as reduce incidences of educational and other placements in too

restrictive settings BCHA targeted children in out of state placements, children at

rsik of residential placement, youth in ABCTC, children in state residental facilities

and children in extended out of home placement. Prior to placement at the Private

Residential School in New Jersey included in the study, adolescents and pre-

adolescents between the ages of seven and fifteen are assessed individually by their

County CART's to determine that all local and less restrictive interventions have

been exhausted. Records are reviewed and interviews are conducted including

Division of Youth and Family Services (DYFS), Educational Out patient and In

patient Counseling, Parental and other documentation.

12

Class B Commnitmet:

Involuntary placement in a New Jersey State Psychiatric Hospital, Class B

Commitment (Involuntary Commitment of Minorts pursuant to R.4:74-7) requires the

signature of two mental health professionals mcluding at least one psychiatist as well

as a psychologist Or psychiatric social worker. This commitment is reviewed at least

every three weeks and certifies that;

I) the minor is menally ill: 2) meornal illness causes the minor to be dangerots

to self or others or property as defined by AJSA 30:4-27.2h and .21, or

alternatively, that the minor is in need of intensive psychiatric therapy which

cannot practiclly orfeasibly be rendered in the home or in the community or

on any outpatient basis; and 3) appropriate facilities, or services are not

available (DHS/DMH&H R.4:74 7).

While some individuals have been placed at New Jersey State Psychiatric

Hospital for Adolescents on a voluntary commitment, this is a rare enough

occurrence as to have no effect upon this study if such cases were separated out into a

separate category for statistical analysis. They will be grouped incluswvely with other

adolescents in the study population,

13

Comorbidiy:

"At its simplest, comorbidlty is the occurrence at one point in time of two or

more DSM-hII-R disorders (Clarkin & Kendall, 1992) " Clarkin and Kendall go on to

define two types of comorbidity. Cross-sectional comorbidity is the type studied in

most previous ADHD/Comorbidity research and will be the major focus of the

present study. Longitudinal comorbidity implies a predictive component of specific

disorders which may precede the emergence of other conditions An example of this

would be specific learning disorders that are comorbid with ADHD and predict a

more negative adolescent outcome than either condition alone (Abikoff & Klein,

1992; Fischer et. al., 1990). This definition of comorbdity will be important when

evaluating the current research problems and applications,

14

Conduct Disorder (CD):

Conduct Disorder will be defined as per the diagnostic criteria in the DSM

IlI-R Conduct Disorder (312). For the purposes of this study, any mention of chronic

problems with "conduct," "aggression," or "socialization" m the pupil's record as

may have been defined using Adaptive Behavior Measures, Connor Scales, or other

objective or informal measures, or Case History, as in a mention of these symptoms

in an earlier report or protocol, or suggestion of CD in the evaluations prepared by a

certified child study team member (School Social Worker, School Psychologist,

Learning Disability Teacher Consultant), clinical staff member (Psychologist.

Psychiatust, Psychiatric Social Worker), will be considered to define the existence of

CD in the individual's clinical picture. As per other studies of comorbidity, CD wili

not be classified into sub groups including Group Type (312.20), Solitary Aggressive

Type (312.00) or Undifferntiated Type (312.90) but all clinical mentions of CD will

be grouped inclusively in this study

15

Depressive Disorders:

Depressive Disorder will be defined as per the diagnostic ritena in the DSM-

ITT-R Mood Disorders. For the purposes of this study, any mention of chronic

problems with "Depression," 'Dysthymia," "Cyclothymia" or 'Bi-Polar Disorder" in

the pupil's record as may have been defined using Adaptive Behavior Measures or

other objective or informal measures, or Case History, as in a mention of these

Symptoms in an earlier report or protocol, or suggestion of depression, vegetative

symptoms, or sucidality in the evaluations prepared by a certified child study team

member (School Social Worker, School Psychologist, Learning Disability Teacher

Consultant), clmincal staff member (Psychologist, Psychiatrist, Psychiatric Social

Worker), will be considered to define the existence of Depression in the individual's

clinical picture. As per other studies of comorbidity, Depression will not be

classified into sub groups including Dysthymia (30040), Cyclothymia (301 13),

Major Depression (296.20), Depressive Disorder NOS. (311.00), Bi-Polar Disorder

Manic (296 40), Bi-Polar Disorder Depressed (296.50) or B-Polar Disorder NOS.

(296.70). Rather, all clinical mentions of Depressive Disorder will be grouped

iclusively in this study.

16

Disruptive Behavior Disorders:

For purposes of this study, Disruptive Behavior Disorders will be defined as

that group of extemallzng behavioral disorders as specifically defined in the DSM-

I1I R.

This subclass of disorders is churactrL ried by behavior that is socially disruptive

and is oftien more distressing to orhers than i rthe people with the disorders. The

subclass includes Attention-deficit Hyperacatvily Disorder. Oppositional Defian

Disorder, and Cnonduct Disorder (DSM II R, p. 49).

Educational Classification

This term will refer to either the process of referral, evaluation by a team of

New Jersey State Certified educational professionals resulting in the educational

classification of a pupil as per NJAC 6:28, sec. 3 or the resulting educational label.

For the population being studied, these labels most often will include Emotionally

Disturbed, Perceptually Impaired, Educable Mentally Retarded, Neurologically

Impaired and/or Multiply Handicapped referring to a combination of the above

mentioned educational classifications (NJAC 6:28, sec. 3.5).

17

Emotionally Disturbed (ED):

Emotionally Disturbed is the most frequent educational classification in the

population as defined in this study and the standard criteria for this classification will

have been applied in all classification conference reports.

"Emotionally Disturbed" means Ihe exhibiting of seriously disordered

behavior over an extended period of time which dversely affects edurcational

performance and shall he characieriLed by (d)o I r ii below An evaluotion

by a psychiatrist experenced m working with children is required. . ar

miabiliv to build or maintain satisfactory interpersonal relationshzps; i.

Behaviors inappropriate to the circumslancey. a general or pervasive mood of

depression or the development of physical symptoms or irrational fears

(NJAC 6:28, sec. 3.5 (d)5).

IS

Learning Disabled (LD):

Learning Disabilities and Specific Learning Disabilities are terms defined by

federal law to necessitate Special Education These terms are generic for a wide

range of academic problems experienced by individual pupils. In New Jersey, the

term learning disability is generally supplanted by the educational classificalion

"Perceptually Impaired." According to some definitions, Learning Disabilities may

include ADHD, but for the purposes of this study, Learning Disabilities such as

reading disorders, sequencing problems, memory problems and dyslexias will be

defined separately as per this general definition:

All learning disabled students have an academic problem in one or more

areas, and this problem iv not primarvyv due to emotional disturbance, mental

retardation, visual or auditory impairment, motor disabritiy, or environmental

disadvantage. In their problem area(s) they are not achieving in accordance

with their potential ability. Social emotional problems may or may not b

present (Haring c- McCfIoraick, 1990, p. 110).

Certain early studies implied that specific reading disabilities, particuarly m

sequencing and word recognition, may have been an element of ADHD, however,

later research distinguished that tis correlation had been due to sampling error and

was a byproduct of the high coincidence of comorbidity between ADHD and learning

disabilities (Cantwell & Baker, 1991, Dykunan & Ackerman, 1991; Love &

Thompson, 1988).

19

Oppositional/Defiant Disorder (ODD):

Oppositional/Defiant Disorder will be defined as per the diagnostic criteria in

the DSM-III-R, Oppositional/Defiant Disorder (313 81) For the purposes of this

study, any mention of chronic problems with "oppositional behavior," or "defiance to

authority" in the pupil's record as may have been defined using Adaptive Behavior

Measures or other objective or informal measures, or Case History, as in a mention of

these symptoms in an earlier report or protocol, or suggestion of ODD in the

evaluations prepared by a certified child study team member (School Social Worker,

School Psychologist, Learning Disability Teacher Consultant), clinical staff member

(Psychologist, Psychiatrist, Psychiatric Social Worker), will be considered to define

the existence of ODD in the individual's clinical picture. Attempts will be made to

discriminate between cases of ODD and behaviors related to Depressive Disorders,

however, in cases where Depressive Disorders are being ruled out in the individual's

psychiatic diagnosis, or where Depressive Disorders are "not otherwise

specified(NOS.)" discrimination may not be possible.

20

ASSUMPTIONS:

The difficulty with any ex postfacto study is its dependence upon pre-existing

records, records that have perhaps been generated by a multitude of different

practitioners. Additionally, this study reviews records generated by a variety of

members of an interdisciplinary team However, the terms being researched are very

well defined either by the DSM-UI-R or by New Jersey Educational Law (NJAC

6:28). It is assumed that all State and clinically certified practitioners, whether Child

Study Team members (School Social Worker, School Psychologist, Learning

Dlsability Teacher Consultant), clinical staff member (Psychologist. Psychiatrist,

Psychiatric Social Worker), will be sufficiently familiar with these diagnostic criteria

as to apply them consistently and within the norms of current clinical practice.

In this way the studies of more diverse population groups may be considered

and compared to one another to establish baseline rates ofcomorbidity among diverse

populations with ADHD and other clinical syndromes, learning disabilities and

disorders as well as establish a history of correlation between conditions comorbld

with ADIHD It is assumed that these may be compared with the current study

population because of standard definitions m use m general clinical practice and

because of certain standards of that clinical practice monitored and up-held by

professionals as well as by the certification process It is assumed that precedent

comparisons and overviews of ADHD comorbiditv studies are equally valid to the

21

present study (Barkley, et. al., 1992; Biederman, Newcorn & Sprich, 1991; Shaywitz

&Shaywitz, 1991).

The random selection of the study population is assumed to be assured by the

rime limit established for gathering the data. The study will encompass only those

adolescents and pre-adolescents who happen to be committed to the New Jersey State

Psychiatrc Hospital or resident at the Private Residential School during the specific

time period of the study. In other words, the study population will consist of those

adolescents identified for Class B Commitment or CART-ed for a particular "most

restrictive" placement during a given period of time The rates of comorbidity of

ADHD and educational classification found during this period of time can be

assumed to be consistent with rates found during any other randomly selected period

at the same or similar in-patient programs

LIMITATIONS:

The consistency of definitions will be limited by the large number of

practitioners contibutrng to the records. There will be variations as per differing test

protocols contributing to the educational and clinical evaluations. These

inconsistencies should be lessened by the careful application of the above mentioned

definitions by a single researcher evaluating all the pertinent records. Additionally,

as mentioned above, these practitioners all used the same DSM-IlI-R definitions in

22

their clinical work. The culture of a shared professional setting should also influence

the individual clinicians to a greater uniformity o practice.

Due to the timeline constrictions of the study, there will be a relatively small

study population of between thirty-five and seventy-five pupils per facility. This

population base is comparable to other in-patient comorbidity srudies and is in fact at

the median between the above-mentioned in patient studies. (Biederman, Newcom &

Sprich, 1991).

Unfortunately, this study will be vulnerable to all of the criticisms that could

be made regarding any of the above mentioned professions or regarding any of the

protocols they may use in diagnosing or evaluating an adolescent. However, the

intensive scrutiny of case histories inherent in the court process which leads to

psychiatric commitment and du ng the CART procedure would tend to insure that if

there were questions of the veracity of these records they would have been addressed

previously. One of the stated purposes of this study is to determine if there is an

appropriate application for ex post facto study of data gathered and generated by

Child Study Teams in educational research and planning.

Finally, the debate regarding ADHD as a discrete disorder or as a subset of

symptoms for other syndromes and disorders continues. Changes m the definition of

ADHD since the 1960's have contributed to this debate The clinical picture

continues to present similarities between symptoms of ADRD and more severe

manifestatios of the syndromes and disorders with which it exhibits the greatest

23

rates of omoribidity (Barkley, 1990; Biederman, Newcorn & Sprich, 1991) Further

research projects, such as the present study, will be necessary to provide a body of

evidence to help resolve this issue in the future

OVERVIEW:

This thesis will be an ex prus facto study of an in-patient population of

adolescents between the ages of twelve and eighteen at a New Jersey State

Psychiatnc Hospital for Adolescents and pre adolescents bewteen the ages of seven

and fifteen resident at a Private Residential School in New Jersey. Access to

pertinent client files, psychiatric evaluations, psychological tests, case histories,

educational evaluations and behavioral logs will be provided in such a way as to

ensure the confidentiality of the individual adolescents and pre-adolescents. This

information will be gathered and synthesized as per the "Definitions" section

parameters above and will be organized into specific populations as per the research

directives in Chapter III

Tn Chapter II, the literature will be researched to identfy rates of incidence of

comorbidlty of ADHD and classifiable educational disabilities in diverse populations

of adolescents and pre-adolescents living m a variety of settings, community,

residential, restrictive and unstructured These populations will be synthesized into a

control group (defined as the independent variable) which may then be compared to

the hospitalized adolescent population (defined as the dependent variable) The

24

incidence rate of comorbidity of ADHD and educational classification in the discrete

hospitalized population of adolescents will be measured via records review,

Chapter IV, will compare these incidence rates and any correlation between

ADHID and educational classification will be computed Correlation between the

identified population of in-patient adolescents and pre adolescents with ADHD -1

educational classification and notations of acting out behavioral problems, such as

delinquency and conduct disorder, will be computed and compared with the above

stated hypotheses as per Chapter V which will also revisit the literature review to re-

examine weaknesses in comparisons between independent study populations as

defined m the "Assumptions" section above

25

CHAPTER I: REVIEW OF LITERATURE

Introduction:

It seems that ADD ADHD is unique to everyone who has it. All the srtoies

hear are somewhat diferent. in our grozp we say that iwe "Blink Out' when

this happens we don't get the message, and don't realize that we even missed

it. 7his can happen anytime We still have the problems of all inforlnwiuon

geaing the same amnoznt of attention and problems with 'filtering" or

'"oclying" Life's a struggle isn't ii. Things are better thogh for me, with

mecs, and a support group I'm having lots of imhprovemenr.

Steven Ledngham.Subj: ADD EvaluationDate: 92-04-28 03:23:19 EDT

From: FNHSteven: Posted on: America Online

26

Taxonomic questions surrounding ADHD and the high rates of related or

comorbid disorders, such as the "splitting lumping" debate (Dykman & Ackerman,

1991) are given a sense of extreme urgency as researchers realize that the definitions

reflect real students such as the one above struggling to avoid clinical outcomes that

are to date, not encouraging (Gittelman, et. al., 1985, Frick, et al, 1991) Definitions

are important only insofar as they lead to targeted treatment and improvement of the

clinical picture over time:

Severe learning deficits in children are quite c.sltly, i terms of both the

enormous expenses relaied to special eduicaion and the personal sufering

and frustration for children and families; furthermore, lthe are quile

persistent, with contnuing achievement difficulties riggering accompanying

problems in self-esteem, peer relations, and adult adjustment....Thus,

developmentl f effective intervention strategies for underachieving children

must be viewed as a major societal issue (Hinshaw, 1992. p. 894).

Splitting individuals into groups and subgroups works for diagnostic purposes.

Lumping best describes the current classroom situationq especially in in-patient

classrooms that service those pupils which are, by definition and early outcome. most

at-rsk, A knowledge of the population to be served is necessary to planning and

implementing treatment (Clarkin & Kendall, 1992),

27

Categories of ADHD are controversial at present. According to Shaywitz &

Shaywitz (1991), "Estimates suggest that ADD affects 10% to 20% of the school age

population." Barkley, et. al (1993) estimate that between 60 and 80% of these

children have comorbid conditions. These conditions may prove to be early

symptoms of developing conditions other than AD-ID or may be different subgroups

ofADHD, as yet undefined clinically (Clarkin & Kendall, 1992).

These issues related to comorbidity and differential diagnosis as well as the

oucomes for students presenting with ADHD and comorbid conditions will be

examined in detail. The differential diagnoses of ADHD CD, ADHID 4- ODD.

ADHD + LD, ADHD + Depression, as well as ADHD + Psychosis will be examined

and defined. A chart will be constructed to define incidence rates of ADI-D

comorbidity and will be compared to two seminal studies of general populations in

New Zealand and Puerto Rico (Anderson, et. al, 1987, Bird et. al., 1988) as well as

earlier m-patient research of populations with ADHD and comorbid conditions

(Woolston, et al., 1988; Biederman; et. al., 1990).

2A

ADHD + CD:

The area of greatest overlap or comorbidity is in the Disrptive Behavior

Disorders (Barkley, 1990). These overlaps occur ia either direction but are very

obviously skewed in the favor of Conduct Disorders having comorbid ADHD

(Shaywitz & Shaywitz, 1991) It has been debated since the beginung of the DSM

effort whether these conditions, CD and ADH-D, are actually separate disorders or

different steps in the progression of a syndrome, "....children with ADDH and ADDH

- CD/OD generally resemble each other more than they differ in sex, age of onset

and presentation, frequency of pennatal insults, psychosocial stress, and impairment

in cogntion and achievement." (Woolston, et. al., 1988).

Barkley (1990) suggests that there may be multiple instances where these

conditions have been misdiagnosed as each other, particularly ADHD and CD, by

practtioners who are not familiar with all of the diagnostic criteria for each

condition. According to the DSM-II-R, there are areas of sigaiicant overlap

between CD and ADHD as well as a developmental quality in that adolescents with

impulsivity are more likely to express it through Conduct Disordered symptomology

and younger children with impulsivity are not likely to have the opportunity to

express those behaviors.

29

Another area in which misdiagnoses may have occurred is in studies of

comorbidity of ADD and Juvenle Delinquency. The conditions for Juvenile

Delinquency closely match the DSM-IJT-R diagnostie cnteria For conduct disorder,

viz; theft (criterion 1), elopement (criterion 2), truancy (criterion 3), breaking and

entenng (criterion 6), sexual assault (criterion 9), assault and assault with a weapon

(criteria 10, t1 and 13), as well as mugging purse-snatching, extortion, armed

robbery (criterion 12). If these activities are treated through the mental health system

they are considered behavioral disorders and if there are charges brought and

sustained, these are considered as Juvenrle Delinquency. Therefore, rates o'

comorbidity of Juvenile Delinquency and ADHD may be considered along with other

rates of comorbid ADI-ID and CD. Moffitt (1990) found significant correlates

between ADD - delinquency and specific reading disorders as well as a predictive

quality for future acts of aggression and vandalism.

Epstein et. al. (1991) found a distinction between referral sources and

diagnosing professionals and the treatment of ADI D - Conduct Disorder and ADIHD

+ Learning Disability as comorbid or overlap conditions. They studied diagnostic

patterns and treatment outcomes from four referral groups: Child Neurology, Child

Psychiatry, Pediatricians and Psychologist clinics. These were out-patient samples

with the exception of the Child Psychiatry sample Out of the population N-82

children with presenting problems of learning disabilities or "school problems,"

n=62 were diagnosed with comorbid ADD (Epstein et. al., 1991). The in patient

sample from the Child Psychiatry clinic were even higher with a significant

30

comorbidity of other behavioral disorders such as CD/ODD and Psychiatc

problems.

Although he found ADHD and CD/ODD to he separate syndromes with clear

distinctions between them, Hinshaw (1992) found several considerations which

qualify these differential diagnoses including familial, socio-economic, definitional,

and social-emotive factors which can effect the labeling of individual cases.

However, Hinshaw found "...overlap between externalizng behavioral syndromes

and under achievement occurs at levels that are far above chance rates (p 895)."

ADHD occurs with a frequency of 3% to 6% of school aged population and CD

occurs in 3% to 7% of this population, according to Hinshaw's sources and he

estimates that these conditions overlap between 10% and 50%.

177 clinically referred boys were tested and diagnosed by Frick et. al. (1991)

and diagnosed with CD or ADD of which n-49 were diagnosed with both. Academic

under achievement was found to be elevated m both the ADD with CD group and the

ADD alone group. Biederman et. al. (1987) found that of N=22 children with ADD,

64% or n-14 met diagnostic criteria for an additional diagnosis of CD/ODD.

Szatzmati et al (1989) found a diagnostic overlap of 40%, and these children

appeared to represent a separate diagnostic category with elevated levels of school

and behavioral difficulties.

As per Hinshaw (1992), Biederman (1991), and others, Abikoff and Klein

(1992) found rates of comorbidity of CD/ODD with previously diagnosed ADHD as

31

20% to 60% These results were markedly skewed in the opposite direction as

children with previously diagnosed CD presented with comorbid ADHD up to 90% of

the time tested. Further, they found this prevalence of comorbidity to be a

chronological comorbidity "In clinical samples, the influence of CD on diagnoses of

ADHD is not straightforward because, typically, the onset of ADHD precedes CD

(Abikoff & Klein, 1992, p. 882)." Therefore, these rates of comorbidity will vary

related to the age of the population sample.

ADHD + ODD:

'he term 'opposizronal defiant disorder' rs applied to a problem that is less

Yerious than a cniduhct disorder but more ssriom than simply being a diffiult

child. Children and adolescents with this condition are persisremiy arrogant,

argumentative, short tempered, resentfll, angry, and defian, especially

towards their parents; it is as though they are trying to be annoying (Harvard,

1989. p. 2).

Most studies have grouped CD and ODD for purposes of measuring rates of

comorbidity with ADHD and, according to Biederman (1991), Barkley (1990) and

IIinshaw (1987), until recently the condition of ODD has been diagnosed as Conduct

Disorder, Solitary, Aggressive Type (DSM-I-R). This diagnosis of Conduct

Disorder has almost completely disappeared or been supplanted by the ODD

diagnosis This may represent an evolution or refinement of the diagnostic process

32

(Fletcher et, al , 1991) or may simply be the nature of Behavior Disorders in general,

Nonetheless, Barkley, et. al., found rates of comorbidity to be significant in at least

two studies of ADHD aud ODD as separate syndromes. "Approximately 40% of the

ADD-I-H children met criteria for oppositional defiant disorder (ODD), and more than

21% received a diagnosis of conduct disorder (CD)...(Barkley, et. al., 1990, p. 780)."

In 1992, Barkley stated, "ODD is known to occur as a co-morbid disorder m as many

as 65% of ADHD children.,.(p 265)."

For the purposes of this study, CD and ODD are being grouped together

statistically This is theoretically supported by Biederman et al (1991 )

In terms of severity of the clinical picture, the available data suggest that

children with aOtenionl deficit hyperactivity disorder plzns opposilions doefiazt

disorder plus oppositional defiant disorder may form in intermediate

subgroup between those who have attentzon deficit hyperactivity disorder

alonie and those with attention deficit hyperactivity disorder pltu Conduct

disorder... These findings are consistenr with the hypothesis that opposirional

defiant disorder may be a subsyndromal manrfestation of conduct

disorder...(p. 569)

33

ADHD 4 LD:

During the 1960's the syndrome of Minimal Brain Dysfunction was globally

defined to include hyperkinesis, specific reading disorders, certain neurological soft

signs, attentional difficulties, impulsivity and minor coordination delays (Clements,

1964). Since that time, further definition of ADHD and LD as separate syndromes

with significant overlap or comorbidity has occurred. Barldey (1990) clarifies this

distinction thusly:

As discussed in Chapter 3, ADHD children are considerably more likely than

normal or control groups of children to display associated problems with

academic achievement skills. language, and motor coordination.

Approximawely 20 to 23 percent will have significant delays in the

development of math reading, or spelling, and 10 to 30 percent may have

problems with language. Parents of ADfHD children also describe their

children as being less coordinated on average, t th those of normal children

(p 186).

The comorbidity of learning disabilities, or specific developmental delays (as

per the DSM-III-R and DSM IV): is one of the most heavily researched areas of

ADHD comorbidity. Cantwell & Baker (1991) catalogue almost two decades of such

research. A 1980 study found that 53% of boys with hyperactivity were

34

underachieving in either reading or math, the 1987 New Zealand study found 80%

comorbidity of ADiHD and LD conditions tn their longitudinal study of N-600

students with speech and language impairments, Cantwell & Baker found that ADID

occurred in 19% of the children. Of the children with clinically significant levels of

LD, the percents were higher with a ADHD rate of 40% initially. At the four to five

year follow up the rates intensified with ADHID occurring in 37% of the total sample

and 53% of the LD sample.

Dvkman & Ackerman (1991) found that almost half of a sample of N=182

children diagnosed with ADHD were clinically reading disabled. Of these n-82

ADHD and dyslexic children, those with other comorbid disorders demonstrated the

most significant performance deficits, "The poorest performers overall were those

with both emotional (internalizing) and behavioral (externalizing) diagnoses

(Dykman & Ackerman, 1991, p. 101)." Barkley, et a]. (1990) found that a cohort of

ADHD children with externalizing behaviors, n-48, were more at risk for special

education placements than ADHD children with internalizing behaviors, n=42

These children all had comorbid LD but were dually diagnosed and were compared

with control groups of normal and LD diagnosed children.

Of N=116 children studied by Love et al. (1988), n=44 or 37.9% of the boys

and n-I2 or 10.3% of the girls were diagnosed with dual language and attention

deficit disorders. Epstein, et.al., (1991) report research results that, "Children im this

group exhibited deficits in lexical decoding and rapid word naming. Such findings

support a language-based deficit for reading disability in children with attention

35

deficit disorder (p 80)." These results were similar to the New Zealand study of the

previous year (Andersen, et. al., 1987). Whereas Love and Epstein attribute these

rates of comorbidity to a possible symptom of language deficit related to ADD,

Andersen like Barkley (1990) treats them as separate syndromes which are found to

be comorbid frequently. Neurological explanations for this overlap have been

proposed but conclusive research has not been forthcoming but this line of reasoning

may be promising (Hinshaw, 1992; Barkley, et. al., 1992).

ADHD + Depression:

Similar speculation as to a neurological or genetic link has been inspired by

the rates of comorbidity of affective disorders and ADHD both in children wirh

comorbid disorders and among their families Barkley et al, (1992) and Biederman,

et al (1990, 1991, and 1990) have provided preliminary epidemiological studies of

this relationship.

Jensen, et. al. (1988), found significant overlap between Major Depressive

Disorder and ADHD to be skewed in the direction of ADI-ID children showing many

more symptoms of Depression than Depressed boys showed of ADHD in a study of

N-35 boys This supports earlier studies that show a significant correlation between

ADHD and the extemalizing/behavioral disorders and a lesser power of correlation

between ADHD and interalizinn/mood disorders (Steingard, et. al., 1991). Barkley,

36

et. al. (1992) found significantly elevated levels of familial and proband comorbidity

of mood disorder, behavior disorder and family conflict t a study of N-83

adolescents and their mothers

Biederman, et. al., undertook two separate studies of children diagnosed with

ADHD and comorbid mood disorders, control groups and their relatives The first

study, N - 73 probands with ADHD, found a 33% rate of comorbid mood disorder,

r=24. Furthermore, the relatives of all the ADIt children, not just those with

comorbid mood disorders, demonstrated a significantly greater risk for ADHD and/or

mood disorders (Riederman, et al, 1990) In 1991, Biederman, et al= studied a

group of 140 probands and their relatives with strikingly similar results. In 1990, he

completed a survey of pnor research in this area and concluded.

?he weight of the available literature indicates thefrequent occurrence together

of conduct. mood, and anxiety disordarrs, as well wu learning disabiliies. with

attention deficii hyperactivity disorder in childhood, adolescence and adulthood.

'he observed comorbidity does not appear to be either random or artifactual.

Rather, specific patterns of symptoms and syndromes tend to occur together in

individulsya andfamilies (fieoderrman. NAew'cor & Sprich, 1990. p.. 74).

37

ADHD + Psychosis:

Many of the out patient studies screened for neurologic insult and psychosis

when developing their study population (Biederman, et al., 1992: Gittelman, et. al.,

1985, Barkley et al , 1992) However, the in patient studies (Woolston, et. al, 1988;

and Szatmari, et. al., 1989) present sub-groupings of ADHD comorbid with atypical

psychosis, as do the two large population studies from Puerto Rico and New Zealand

(Bird, et. al., 1987, and Andersen et al, 1985).

This provides a significant sub-grouping of children with multiple diagnoses.

Barkley (1990) calls this the "Multiplex Developmental Disorder" or mixed thought

and affective disorders (p. 196). These children meet all DSM-If-R criteria for

Atypical Psychosis (298.90) as well as presenting with specific developmental

disorders and ADHD. They form a small but statistically significant grouping of the

in-patient populations in these studies and present with the worst prognoses

educationally and socially. Their influence will be discussed further with the specific

in-patient population studies by Woolston ( 1988) and Szatzmari (1989).

Features of Atypical Psychosis and the MDD child, according to Barkley

(1990) include specific developmental disorders, thought disorders, odd or peculiar

behaviors, ADHD, and severe social and adaptive deficits especially in the area of

interpreting and presenting social cues. These symptoms are considerably weaker

38

than those associated with autism or schizophrenia but are global, pervasive and

comorbid (Barkley, 1990) Children and adolescents with MDD or atypical psychosis

are uniquely challenged among comorbid ADHD subgoupings in that they have a

very high level of peer rejection (Abikoff Klein, 1992; Fletcher, et a., 1991). They

will form a significant subgrouping in the study population.

Comorbidity Issues:

The debate regarding comorbidity is raxonomTe and epidemiological in nature

and, thus, integral to the present discussion. Is ADHD a separate disorder or grouping

or symptoms endemic to several subcategories of other syndromes. Barkley (1990)

devotes most of "Chapter Six: Differential Diagnoses" to this question "Minimal

Brain Dysfunction" lumped several conditions together which are considered to be

highly comorbid but distinct syndromes today.

Splitting diagnoses too greatly has its own taxonomic disadvantages as

demonstrated by the debates surrounding the DSM-III, DSM-III-R and DSM IV

definitions of attention deficit and evolution from attention deficit disorder (ADD) to

attention deficit disorder plus hyperactivity (ADD+H) and attention deficit disorder,

undifferenuated (ADD- or ADD without) as per Barkley et. al., (1987). DSM IV

categorized ADHD as a separate category of disorders with a diagnostic choice of

discriminating between ADHD, Combined Type, ADHD, Predominantly Inattentive

Type, ADI-D, Predominantly Hyperactive-lmpolsive Type and ADHD, NOS (DSM-

IV, p65).

39

Yheoretically it is important to consider the hierarchrcal nature of a

diagnostic ,ywtrem. Followed in a rigid manner, excltsionrwy rules could limit

the aczmnmlarion of important data antd narrow the fbcus of the clinician. To

advance thefild, futurre research must noa only continue to use crireria based

on empirical daia hut mnst also address the potential shortcomings of a

hierarchical diagnostic system...(Clarkin & Kendall, 11992, p. 9071

Each of the comorbid conditioas considered in the study encompasses a range

of diagnostic ritena with a range of potential interpretations In examning case

histories and diagnostic processes for individual children, there is a notable range of

diagnostic impressions However, these fall into the general composite groups of the

DSM-JII-R as well as the general groupings of either extrinsc/behavioral or

intrinsic/affective disorders (Jensen, 198S; Bird, 1987), behavioral disorders,

depressive disorders, psychoses, specific developmental disorders (DSM-III-R,

Barkley, 1990) or learning disabilities and behavioral disorders (Shaywitz &

Shaywitz, 1991, Epstein, et. al, 1991) and so on used in the above mentioned studies

since the New Zealand and Puerto Rican surveys of DSM-mI diagnoses and

comorbidity.

This diagnostic category approach to "lumping" serves to weight the statistics

in favor of broader comorbid tendencies and is justified by the multimodal approach

to treatment favored in both out-patient and in-patient clinics today (Abkoff & Klein,

40

1992). For the purposes of this study, such lumping will be continued in these pre-

established groupings. "For both clincally derived and quantitative classifications of

attention-related disorders, the crux of the problem is how to disentangle the disorder

of interest from other, overlapping disorders (Fletcher, et. al. 1991, p 72)" For the

purposes of this study it does not matter. Hierarchical and taxonomic considerations

are secondary to the applications of this research in existing special education

classroom environments Under New Jersey law (NJAC 6.28, sec. 3.5), diagnostic

lumping is necessary and under the Plan to Revise, lumping solely by behavior and

educational requirements is mandated (NJAC 6-28, sec. I ).

At-Risk Populations:

Two of the most influential studies of rates of ADHD as well as rates of

ADHD with comorbid conditions, in the general population were the New Zealand

study (Andersen, et al., 1985) and the Puerto Rico study (Bird, et. al., 1988). They

are significant for their large populations and are considered to be extremely adept in

their ability to accurately represent the population at large. In New Zealand, N-792

eleven year olds were studied longitudinally over a penod o six years duration. The

Bird ('1988) study provided an epidemnological survey of a probability sample of the

entire Puerto Rican population aged 4 through 16 years using two groups of n-777

and n-386 for a total study population of N-1163. Studies of such magnitude

provide a large degree of statistical power and are very expensive to replicate. These

41

two studies have provided important baselines for companson research of specific,

smaller populations since they were first published.

In the first year of the New Zealand study (Andersen, et. al., 1985), a group of

n=53 children were identified to have ADD, "...the most strongly supported category

was ADD, followed by conduct disorder (p. 72)." Of n-219 cases of classifiable

DSM-IH disorders, includin the ADD category, there presented a 55% rate of

comorbidity. Of these children a subgroup of n=14 children with multiple

intemalizingioehavioral disorders was signficant in that they accounted for a

disproportionate amount of the single diagnoses in the study. An additional group of

n-15 children had ADD plus CD/ODD. These figures were followed up by

additional parent and teacher interviews for certain subgroups of classified children.

The longitudinal results are significant for the study at hand; "For the other groups,

particularly the group with multiple disorders and that with ADD plus conduCt-

oppositional disorder, teacher-reported aggressivity increased markedly with age

(Andersen, et. al., 1985, p. 73)" Additionally, these two groups were most likely to

be referred for clinical assistance. This is the subgroup, n-29, that most resembles

the study population of in-patient adolescents and pre-adolescents and provides the

appropriate baselines for this study

The results of the Bird, et. al. (1988) study were weighted against the 1985

census of Puerto Rico and were carefully matched against the cenisus population, age

range and socio-economic data. It is also a large sample survey and thus has very

high correlational power. The results were a rate of ADD of 9.5% of the study

42

population and estimated 6.6% of the general population of Puerto Rico.

Comorbidity rates of four diagnostic domains was computed as per the following

chart (Bird, et. a]., 1 988 p 1124)

AC T IE CD/ DOM A S>_ I_ Afl7 IAET

ArFECTIV ' I--([n-O) 51 70%f(n=2T) 30.70% (n-iS) 31. a%(n-=1)

C"D/IOD 2 930% n=27') (n=118) 44.70% (n-55) 34.70% (n-36)

ADD 17 00% (n= 8) 53.60e/ [n-55) in-s) .22.60o nn=23ANXElrV 16.,0% (n-=9) S39.20%1n=36) 21.20% (n=23) (n=8l)

WEIGHTED % (UNRW ITHTED N)

Table 2.1

Significant to the study, the comorbidity between the ADD and CD/ODD

groups was significant. The two groupings CD and ODD were combined as they will

be mi the study population. The findings statistically among Puerto Rican study

population and among the weighted census projections were significant and will also

be used as baselines for study comparisons "More than half of the children classified

as having ADD were also classified as having Conduct/Oppositionai Disorders, and

almost half of the conduct/Oppositional group were also classified as having ADD

(Bird, et. al., 1988, p. 1124)"

43

In-Patient Studies:

The most relevant comparisons among previous study groups and the current

study population will be found in the few studies that employ in-patient cohorts

among their proband population groups. As defined in Biederman, et. al. (1991),

there is only one study in which the entire cohort is in-patient youth, Woolston, et.

al(1989). According to the Biederman survey, Strober (1988) evaluated the families

of in-patient youth, Epstein, et, al. (1991) uses an in-patent cohort "The child

psychiatrc-referred group was composed of children referred to an in patient child

psychiatry service and may not be totally representative of children seen as

outpatients in mental health centers (p 84) " This group is weighted heavily in the

present comparison study and will be considered both as grouped with the general

population study by Epstein and as a separate cohort,

Woolston et. al. (1988), studied N=35 hospitalized children between the ages

of 4 and 14. There is great overlap between Woolston and the present study. In fact,

Woolston's first two hypotheses differ from the hypotheses of the present study

mainly in that he focuses on demographics where the present study focuses on

educational classifications (Woolston, 1988, p. 708);

I. 7he prevalence of mixed behavior and affective/lanfely disorders wilt hehigher in pvychiatric inparients than m outpatient.s

2. Children with behavoral disorders only and those with mixed behaviorand raffective.n.iety disorders will have sinlilr demographic and cognitivechuarcteristics.

44

The sample consists of n=35 children with behavior disorders from a

population of N-65. These children were screned for Psychosis and other "organic"

syndromes such as mental retardation, Tourette's, pervasive developmental disorder,

etc. Of this cohort, there was a comorbidity in all three domains of cognitive,

behavioral and affective disorders as per DSM -ITTR diagnoses for n-35 children. An

additional n=17 children were comorbid in two domains and n=7 children only

presented with behavioral disorders (Woolston, et al, 1988).

Although the present study has many parallel features with the Woolston

study, it is by no means an attempt to replicate this study. Rather, the present study

builds upon Woolston's work. Both studies are comparable because they rely upon

previously determined DSM-III-R diagnoses and examples of adaptive, social and

educational skills for the specific ADHD cohorts However, the present study begins

with a group that is both educationally classified and ADHD. The present study will

return to Woolston's findings:

The hyporthesis that those children with mixed disorders would be more

impaired wax not supported by this sludy. In fact, those differenes found

hetween groups in adaptive behavior idicated tha the Beh. - Aff./Anx

group exhibited more age appropriate kills in the area of daily Irving skills

(p. 711).

45

... / a substantial number of children (21/35) who were in fact having

significant academic difficultiy These children were equally distributed in

both groups and represent a diagnostic category represenming considerable

clinical concern. These children with learning disabilities and borderline

funcioning evidenced impairment in all areas ofbehavror (p. 712).

The current study will create a grouping of children with ADHD, LD and

other behavior disorders as well as groupings of children with ADHD, LD and

Affective disorders, such as Depression Children vwth comorbid Psychosis may also

be considered. It is presumed that these children may comprise the significantly at-

risk group with "impairment in all areas of behavior," mentioned by Woolston, et.

al.(1988) and alluded to by Biederman, et. al. (1991) and Barkley (1990).

46

Summary:

The above studies have been organized delineating various rates of

comorbidity among the various populations, population and comorbid conditions

researched. Some study populations were listed multiple times as they were divided

into multiple comorbid sub groupings. The appropriate mean rates of comorbidity

were computed for a general population, a specific ADHD population, in patient

populations and out-patient populations Correlation's between various conmoibid

conditions and ADHD will be computed For significance, as per the large population

studies of Andersen et. al., (1985) and Bird et. al., (1988). This data will be

compared with the study population of adolescents and pre-adolescents in the two in-

patient programs (on a given date as per the Jensen, et. al. (1988) methodotogy)

These charts will be presented as part of the chapter on methodology and the

computations related above will be presented among the study results

47

CHAPTER 111: DESIGN OF THE STUDY

SAMPLE:

The sample will be drawn from the total population of children resident in the

two programs specified above, the New Jersey State Psychiatric Hospital for

Adolescents and the Private Residential School in New Jersey, on a specified date.

Determining a specific date and choosing the total resident population at that time

will ensure random selection as any child who is mentally ill and educationally

classified in the state of New Jersey may or may not be eligible to reside at the above

facilities on any given date through the process of the CART team or "Class B"

Commitment.

From the sample of the total population on that date, a sub-grouping of those

children who have been diagnosed with Attention Deficit Hyperactivity Disorder

(ADHD) will be drawn. Due to the requirements of the CART team process and/or

the "Class B' commitment process, all of the population will be diagnosed with a

mental illness as per the DSM-III-R and will be educationally classified or referred

for child study services.

MEASURES;

This is an ex post facto study of the subject's records in residential school

facilities. No measures, either formal or informal will be administeredr The subjects

Aidll not be interviewed and have been previously diagnosed and classified via the

facilities admissions procedures, either by the CART team process or "Class "3

commitment

DESIGN:

This is an expostfacto study of the records of subjects who reside at the New

Jersey State Psychiatric Hospital for Adolescents and the Private Residential School

in New Jersey, on a specified date. These records will be used to determine the

subject's educational classifications and DSM-III-R diagnosis or diagnoses. The

number of subjects with ADHD will be determined per each population and the rate

of ADHD will be computed for the entire study population. For the puposes of these

calculations, a subject will be considered to have ADHD if they have a DSM I- R

diagnosis of ADFID (31401) or ADD (314,00), or with a history of Ritalin

(methylpherudate) use as Ritalin is not prescribed for any other treatment purpose

19

except to geriatric populations as per the PDR (Physlcian's Desk Reference; Barkley,

1992)

From the group of subjects determined to have ADHD, the following groups

and subgroups will be determined; subjects with ADHD and Educational

Classification, subjects with ADHD and Conduct Disorder/Oppositional Defiant

Disorder, subjects with ADHD and Depression, subjects with ADHD and Learning

Disabilities (i.e. Specific Developmental Disorders and&or Educational Classifications

other than Emotionally Disturbed) and subjects with ADHD and multiple disorders as

specified above, Subjects may fall into more than one of the subject groups

The rates of occurrance and correlates between subgroups will be computed.

These statistics will be compared in detail with the study findings in Chapter II and

made into chart The two large population baseline studied, Andersen et. al. (1985)

and Bird et. al. (1988), will be considered a control group (defined as the independent

variable) which may then be compared to the hospitalized adolescent population

(defined as the dependent variable).

TESTABLE HYPOTHESIS;

I The incidence of co-morbididty of ADHD and Classification among thein-patient adolescents and pre-adolescents will be higher than theincidence among more diverse population groups.

II. There will be a statistically significant correlation between ADHD andClassification in the in-patierl adolescent and pre-adolescent population.

III. There will be a statistically significant correlation between ADHD +Classification and other behavioral problems in the in patient adolesecentand pre-adolescent population

50

SUMMARY:

This will be an ex postfacto study of an in-patient population of adolescents

between the ages of twelve and eighteen at a New Jersey State Psychiatic Hospital

for Adolescents and pre-adolescents bewteen the ages of seven and fifteen resident at

a Private Residential School in New Jersey. Access to pertinent client files,

psychiatric evaluations, psychological tests, case histories, educational evaluations

and behavioral logs will be provided in such a way as to ensure the confidentiality of

the individual adolescents and pre-adolescents. This information will be gathered

and synthesized as per the "Definitions" section parameters in Chapter I and will be

organized into specific populations as per the research directives listed above.

51

CHAPTER IV: ANALYSIS OF RESULTS

ORDER AND ORGANIZATION OF RESULTS:

The sample population was drawn from the total population of children

resident in the two programs specified above, the New Jersey State Psychiatic

Hospital for Adolescents and the Private Residential School in New Jersey, on

October I , 1994. On this date there was a Population of N= 12 subjects residing at

the two facilities with birthdays between 09/12/87 and 01/18/77 making the study

group's age parameters from 7 years, I month to 17 years, 7 months The population

was overwhelmingly male with only 22 females or 19.6 %. Of these subjects n-48 or

42.9 % presented with Attention Deficit Hyvperactivity Disorder (ADHD).

The population of subjects at the New Jersey State Psychiatric Hospital for

Adolescents (To be referred to as the "Hospital Population") was N-39, with ages

between 12 years, 0 months and 17 years, 7 months (birthdays between 10/08/82 and

01/18/77). There were 17 males and 22 females in this group. The rate of ADHD in

the Hospital Population was found to be n- 0 subjects or 25.6 %. The Population of

subjects at the Prvate Residential School in New Jersey (To be referred to as the

"Residential Population") was N-74, with ages between 7 years, 1 month and 15

52

years, I month (birthdays between 09/12/87 and 09/03/79). This Residential

Population was entirely male. The rate of ADHD in the ResidentiaL Population was

found to be n=38 subjects or 52 %. Both groups were found to be extremely

homogeneous in terms of socio-ecnomic status (low) and cultural makeup

(integrated).

RESTATEMENT OF HYPOTHESIS;

Given the severity of symptomology required for a Class B commitment or a

"most restnctlve" educational program placement via the CART process, it is

hypothesized that the study population will present with a measurably higher

incidence of both ADHD then the general population. Further, it is proposed that the

study population will present with a significantly higher incidence of ADI-ID

Educational Classification than a more diverse population educated in a variety of

settings identified via a literature review. Likewise, the rate of cororbidity of ADHD

and education classification should be significantly higher in the study population

when compared to populations m less restrictive settings

The correlation between ADHD and educational classification m the inpatient

study group is hypothesized to be statistically significant and will be comparable to

correlation's of comorbidity found in earlier inpatient studies of ADHD populations.

It is further hypothesized that there will be a statistically signficant correlation

53

between the study group with ADHD educational classification and other comorbid

behavioral problems such as CD, ODD and/or Depression

I. The incidence of co-morbididty of ADHD and Classification among thein-patient adolescents and pre-adoleseents will be higher than theincidence among more diverse population groups

II. There will be a statistically significant correlation between ADfH-D andClassification in the in-patient adolescent and pre-adolescent population.

Mlu. There will be a statistically significant correlation between ADHD +Classification and other behavioral problems in the in patient adolescentand pre-adolescent population.

INTERPRETATION OF RESULTS;

The statistical analyses were performed on the population sample as a total as

well as on the two discrete sub-groups of Hospital and Residential Populations. The

first analyses was percentages of various sub-groupings of the population in terms of

percent with ADHD as stated above. Next, analyses was made of percents with

psychiatric diagnoses (as per the DSM-1II-R,

Depression,

I987) in the four sub-groups of

Psychosis, Conduct Disorder and/or Oppositional Defiant Disorder

(CD/ODD), and Multiple Diagnoses. Percentages of the population with dual

diagnoses of the above disorder as well as ADHD were also computed as in Table

4.1:

i54

IVjP TYPE ITOTAL 96 OF N O ADID

(population) N= 113 10000%ADHD population (n-) 481 42.50% 100.00%Depression 33 29.20%ADHD t Depressin 6.0% 14.60%Fsychosis 50 4420%ADHD+ Psychosis 1 16,80%.. 39 60%

CDUODD 52 46.00%ADHD + CD/ODD 26 23.00% 54.20%

LD(dEL Clasification) 107 94.70%

ADHD + LD 48 42.50% 100.00%Mult 20 17 70%ADHD + Multi 6 5.0% 2 50/

Table 4 1

Similar percentages were calculated for each of the sub-groups. The Hospital

Population totals and percentages are represented in Table 4.2 and the Residential

Population totals and percentages are represented in Table 4.3:

GROUP TYPE ITOTAL %6 Of t 6 of Abt

(population) N- 39 100.00%ADHD pDpulation (n=) 1_ 25.So0% 100 00%Depression 20 51.30%ADHD + Depressiun 4 10.30% 40,00%Fsychosis 22 56.40%

ADHD + Psychosis 7 17 90% 70.00%

CD/ODD 16 41.00%__ADHD + CD/ODD 6 15,40% s60 o/LD(Ed. Classificatin) 33 84.60%AOHD + LD 10 100.00% 100.00%

Multi 17 4&60%__

ADHD + Multi 15 40%' 60.00%

Table 4.2.

TOTAL GROVP

HOSPITAL

55

RE_ SD EONT R ffALGROV'J Pi-' TOTAL % OF N 6 OF AID-D

(population) N= 74 1OI00%P

ADHD population (n-] 38 51.40% 100.00%Depression 13 17.60%ADHD + Depressior 3 4 10% 7.90%Psychosis 26 37.80%APDH + Psychosis 12 16.20% 31 B50D

CD/ODD 86 48.60%ADHD + CD/ODD ?0 27.00% 52.60%LD(Ed. Clasication) ' 74 100 o0%ADH LD 3 51 40% 100.00%

Multi "3 4,10%_____ADHD + Muhi 0 0.00% 00%

Table 4,3.

The above proporttons were compared to the rates of occurrence provided by

the two large population studies discussed in Chapter 2, the New Zealand Study

(Andersen et al, 1985) and the Puerto Rican Study (Bird et al 1988). As stated

above, these studies have been used repeatedly to provide baselines due to the care

with which they were executed Also, due to their large population base, they have a

very high degree of statistical power. Since these two studies provide the comparison

baselines for many of the other studies of ADHD comorbidity quoted in the current

research, using them improves the validity of any comparisons of results.

The rates of occurrence above were compared with the New Zealand (1985)

and Puerto Rican (1988) studies using a hypothesis Z-test of two population

proportions. The Null Hypothesis was that the rate of occurrence found in the study

population was less than or equal to either the Andersen (1985) or the Bird (1988)

56

results. All of the Test-Z scores were calculated with a 01 significance level. These

results are listed in Table 4.4 below:

POPVL.AT1ON A&IR-N DTNV= tet rz ctic al test z critical t

TOrtAAtlt^H 11.3019| 2 326 10.9767 2 S3HO--P/A)--D 4 3B45 2.-3268 3 7G4 2.326

ES/ADHD 1l.2 11.1980 2,26 11 6.S3 2.325

Table 44

As per the above table, all of the statistical Z-scores were significantly enough

above the critical Z-scores (2.3268) to reject the null hypothesis with a 99% level of

confidence. These results were significant across both sub-groups and in comparison

to both the Andersen (1985) and the Bird (1988) study baselines,

A final hypothesis test was run to determine the homogeneity of the

population sample. The population proportions of ADHD were compared between

the Hospital population and the Residential Population with mixed results. The null

hypothesis xwas that the two populations were equal. At a .01 significance level, the

null hypothesis was rejected with a Test-Z score of-2.6286, and a Critical Z score of

4-/- 2.5762. However, the range of confidence was from - 0 5091 to 0.0051 which

includes the Test-Z score. When the test was recomputed at the .05 sigificance level

the results were similar with a Test-Z score again Falling within the standard error of

measurement of -.44885 and - 0654. This reduces the confidence in the internal

consistency of the Total Population sample to less than 95%.

In computing correlation's, a non-parametric ranked correlation was

considered to be more appropriate than a linear correlation. The resulting

57

correlation's were quite high, in the strongly significant range (greater than r- 8)

Because of the internal consistency issues, the ranked correlation's of the sub groups,

Hospital and Residential Populations, these correlation's were only calculated to the

.05 significance level. The Hospital Population ranked correlation between ADHD

and Educational Classtfcaton was r=.877 with a standard error of measurement of

+/- 1.29. For the Residential Population, the ranked correlation between ADHD and

Educational Classification was r-.982 with a standard error of measurement of 2 71.

These correlation's included all of the Educational Classifications listed in Table 4 5

opuiMATin :ED MH P1/NI tEo

TOTAL 80 19A.DHD _ 36 11 tHOSpP 22 5 6 6HOV/APD l 7 0 0

Rts 5]8 14 2 0R:ES/ADi-D 2g 1 0

Table 4 5

The Total Population correlation's were calculated to a 01 significance level.

The first correlation compared ADHD and Educational Classification as per the

above Table 4.5. This ranked correlation was found to be .985 with a standard error

of measurement of +/- 3.67. The Total Population sample was then measured for

correlation of ADHD and Diagnosis with a ranked correlation of .854 and standard

error of measurement of +/- 9.66. This high variance may be secondary to the

weakened internal consistency of the total population sample mentioned above.

These rates of diagnosis were taken from Table 4.1.

58

Before leaving the comparisons of rates of occurrence, another method of

demonstrating significance was supported by these statistically significant hypothesis

tests and correlation's, The rates of occurrence of dianoses in the total population

was compared with the rates of occurrence of diagnoses in the ADHD population.

The same calculatious were made for the Hospital and Residential populations as in

Figure 4 1

DIAGNOSESTOTAL AND PROGRAMS

Muti -CDfODP -

Psychoss -Depression -

I 1N '.jkI .I

40

60

* RES/ADHD RES.

* HOSPiADHD HOSP.

] ADHD H TOTALFigure 4.1.

Further, the rates of occurrence of specific Learning Disabilities (LD) as per

State oF New Jersey Educational Classifications of Emotionally Disturbed (ED),

Multiply Handieapped (MH), and Perceptually Impaired (PI) or Neurologically

Impaired (NI). Regular Education (REG) comprises those students who had not been

educationally classified at the time of the study. It should be noted that of the n=6

students in this group, five have since been referred for educational evaluation and

four have since been classified educationally as per NJAC 6:28. The results of these

comparisons can be found in Table 4.2.

59

CLASSIFICATIONS (LD)TOTAL AND PROGRAMS

!B:ED MH PINI REG

n TOTAL A DHD

I HOSP. , HOSP/ADHD1 RES. I RESIADHD

F'iture 4.3,

STATEMENTS OF SIGNIFICANCE:

The results of the current research in relation to Hypothesis I above support

rejection of the null hypothesis of an equal or simil.ar incidence of co-morbidity and

support the theory that the incidence of co-morbidity of ADI-ID and Classification

among the in patient adolescents and pre-adolescents is significantly higher than the

incidence among more diverse population groups. These results were to reject the

null hypothesis with a 99% level of confidence and significant hypothesis Z-rest of

two population proportions were found for the total population sample and both sub-

groups

0

60

Regarding Hypothesis II, the current research failed to support the null

hypothesis that there was no statistically significant correlation between ADHD and

Classification in the study population and found a significantly strong correlation

which supported the hypothesis. The ranked correlation between ADHD and

Educational Classification was found to be r-.985 for the Total Population sample

with a 99% level of confidence.

Similarly, hypothesis 111 was strongly supported by a statistically sigmificant

correlation between ADHD, Classification and other behavioral problems as

corroborated by the co-morbidity of ADHD and psychiatic diagnosis Here the

correlation between ADHD and Classification and Diagnosis (Other Behavioral

Disorder) was found to be r-.854 with a 99% level of confidence using a ranked

correlation.

All of the null hypotheses were rejected as per the results and statistical

testing procedures outlined above. These results were found to be consistent in

comparisons of the study population as a whole as well as m comparisons of the study

populations as two discrete groups defined as Hospital and Residential in the above

charts Statistical tests of these sub-groups similarly failed to support the null

hypotheses and yielded significant correlation's between ADHD and Classification.

The sub-group populations were not large enough to test for correlation between

ADHD, Classification and other behavioral problem with any statistical strength.

61

SUMMARY:

in Chapter [L, the literature was researched to identify rates of incidence of

comorbidity of ADHD and classifiable educational disabilities in diverse populations

of adolescents and pre-adolescents livng in a variety of settings, community,

residential, restrictive and unstructured Two studies, Andersen et. al. (1985) and Bird

et. al. (1988) were used as a control group(defined as the independent variable)

which was compared to the Hospitalized and Residential populations (defined as the

dependent variables) The incidence rate of comorbidity of ADHD and educational

classification in the discrete hospitalized population. of adolescents were measured

via expos facto records review.

Incidence rates were computed as was correlation between ADHD and

educational classification. Correlation between the identified population of in-

patient adolescents and pre-adolescents with ADHD + educational classification and

notations of acting out behavioral problems, such as delinquency and conduct

disorder, were computed and compared with the above stated hypotheses. All of the

studies' null hypotheses were rejected and the stated hypotheses were supported with

a 99% level of confidence.

62

CHAPTER V. SUMMARY AND CONCLUSIONS

ABSTRACT:

This thesis is an ex post facto study of an in patient population of 39

adolescents between the ages of twelve and eighteen at a New Jersey State

Psychiatric Hospital for Adolescents and 74 pre-adolescents and adolescents between

the ages of seven and fifteen at a Private Residential School in New Jersey. Of this

population of N=ll 3, n-4S were determined to have Attention Deficit Hyperactivity

Disorder (ADHD) with an incidence rate of 42.5%. Sigificant co-morbidity of

ADHD and Depression, Conduct Disorder/Oppositional Defiant Disorder, Psychotic

Disorders, and Learning Disabilities were found The incidence of co-morbidity of

ADI-fD and Educational Classification was found to be significantly higher than the

incidence researched among more diverse population groups as represented by the

New Zealand (Anderson et. al., 1985) and Puerto Rico (Bird et. al., 1988) large

population surveys. The ranked corrclation's between ADEID and Educational

Classification was found to be r- 985 (i> .01), and between AD-D, Classification

63

and Other Behavioral Disorders was found to be r-.854 (P> .01) This procedure

supports the premise of utilizing Child Study Teams to provide data to plan globally

and progammatically as well as to prepare individual education plans

CONCLUSIONS:

In the total population studied, N=113 aged from 7 years, 1 month to 17 years,

7 months, presented with the following proportions of psychiatric diagnoses as

defined in Chapter One: 42 50% with ADHD; 29.20% with Depression; 44.20% with

Psychosis; 46% with CD/ODD; and 94.70% classified educationally. As the above

numbers would show, 17.70% presented with multiple diagnoses Of those students

diagnosed with ADHD (42.50% of the total populations) 14.60% presented with

comorbid Depression, 39.60% had comorbid Psychosis, 54.20% had comorbid

CD/ODD and 100.00% had educational classifications. The rate of multiple

diagnoses other than the comorbid ADHD was 12.50% of this group

These rates were found to be significantly higher for the study population than

For the general populations o the control groups defined by Andersen et al. (1985)

and Bird et. al. (1988). The hypothesis test against the Andersen study shows a test z

of 11 30 with a critical z of 2.33 showing significance with a 99% level of

confidence The hypothesis test against the Bird study was similarly significant with

a test z of 10.98 and a critical z of 2.33, again showing significance with a 99% level

of confidence. A hypothesis test of internal consistency between the two pools

of subjects comprising the study population at both a New Jersey State Psychiatric

64

Hospital for Adolescents as well as the Private Residential School for Boys in New

Jersey was not significant implying that the two populations were the same showed

significant variance at both the 95% and 99% level of confidence. These tests were

not conclusive within the full range of confidence interval limits but were significant

enough to warrant study of both populations as individual groups

The Hospital population was a mixed sex group of 17 males and 22 females,

This population of N-39 ranged m age from 12 years, 0 months to 17 years, 7 months

and ptesented with the following proportions of psychiatric diagnoses: 25.60% with

ADHDl- 51.30% with Depression; 56.40% with Psychosis; 41.00% with CD/ODD and

84.60% with educational classifications. There was an overlap of multiple diagnoses

in 43.50% of these cases. Of the ADHD subgroup (n-10), 40 00% had comorbid

Depression; 7000% percent had comorbid Psychosis, 60.00% had comorbid

CDiODD and 100.00% were classified educationally. The rate of multiple diagnoses

other than the comorbid ADHD was 60.00% of this group. Although the hypothesis

tests for this group were significan to a 99% confidence level in comparison to both

the Andersen et. al. (1985) and Bird et. al. (1988) studies, the test z was much closer

to the critical z than in the total population. Compared to the Andersen study, the

test z was 4 36 and the critical z was 2 33 and the Bird study comparisons showed a

test z of 3.77 and a critical z of 2.33.

The Residential populaton was an all male group ofN-74 ranged in age from

7 years, I month to 15 years, 1 month and presented with the following proportions of

psychiatric diagnoses. 51.40% with ADHD, 17.60% with Depression, 37.80% with

65

Psychosis; 48.60% with CD/ODD and 100.00% with educational classifications.

There was an overlap of multiple diagnoses in only 4 10% of these cases. Of the

ADHD subgroup (n-38), only 7.90% had comorbid Depression, 31.60% percent had

comorbid Psychosis, 52 60% had comorbid CD/ODD and 100.00% were classified

educationally There was no incidence of multiple diagnoses other than the comorbid

ADHD among this group. The hypothesis tests for this group were significant to a

99% confidence level ii comparison to both the Andersen et. al. (1985) and Bird et

al. (1988) studies, and strongly influenced the total population scores Viz., compared

to the Andersen study, the test z was 11.98 and the critical z was 2.33 and the Bird

study comparisons showed a test z of 11 57 and a critical z of 2.33.

Hypothesis testing for correlation's involved ranked correlation tests. It was

felt that non-parametnc statistics were appropriate to the study of population

proportions and ranked diagnoses, The ranked correlation's between ADI4D and

Educational Classification was found to be r-.985 (P> .01), and between ADIHD,

Classification and Other Behavioral Disorders was found to be r.854 (P> .01). The

tested conditions yielded very high correlation's due to reasons to be considered

during the discussion of the above results.

66

DISCUSSION:

The current studies' findings have been strongly supportive of the existence of

significant cornorbid groups among the study population. The incidence rates of

comoibid ADHD and CD/ODD, ADHD and Depression, as well as ADHD and

Psychosis These findings will best be reviewed in individual sub groups despite

some overlap of diagnosis

The incidence of ADHD and Learning Disability as defined by Educational

Classification was very large with a correlation (rt.985 P> .01) approaching 1 0'

This near-perfect correlation may be due to the admission cntena for the most

restrictive educational settings represented by the Hospital and Residential programs

via the CART and Class "B" hospitalization procedures it further demonstrates the

degree to which this comorbid population remains significantly "at nsk" for negative

academic outcomes and requires educational interventions supponing the findings of

Moffitt (1990) and Frick et. al, (]991), and For special education placement as per

Barkley (1990) These rates were similar to the New Zealand study's rate of 80%

comorbidiry of ADHD and LD conditions (Andersen et, al., 1987).

The rate of comorbidity of CD/ODD and ADn-D in the study population was

54.20%. The individual subgroups of Residential (52.60%) and Hospital (60 00%)

populations were Fairly consistent with the total population rate. These rates were

significantly higher than the Andersen et. al. (1985) and Bird et. al. (1988) population

studies. As far as other studies of smaller, but equally heterogeneous populations in

Terms of educational and residential environments: Frick et al (1991) found a

comorbidity rate of 26 7% with CD and ADHD among clinically referred boys;

Biederman et. al. (1997) found a rate of 64% comorbidity of CD/ODD and ADHD;

and SzaLtzari et.al. (1989) found a diagnostic overlap of 40% Barkley (1990) found

an incidence rate of 40% for ADHD with comorbid ODD and a rate of 21% for

comorbid ADHD with CD.

Comparisons with the present study results are difficult because the grouping

included both CD and ODD as one diagnostic category as per Biederman et. al

(1991), Barkley (1990) and Hinshaw (1987), therefore skewing the results towards a

higher incidence rate. However, these rates would seem to be comparable with the

above named studies as per Abikoff and Klein (1992) where rates of comorbidity

between CD/ODD and previously diagnosed ADHD were found to range from 20%

to 60%. The present study, representing an in-patient, and therefore more

significantly impacted population, would be expected to fall into the high end of that

range.

There were less study groups of comorbid ADHD and Depression In the

current study populaton, the rate of comorbidity was only 6.20%. The Hospital

population sub-group had a comorbidity rate of 10.30% and while the Residential

population only presented with 4 10%. In the Biederman et. al. (1990) study of n-73

probands with ADHD, he found a 33% rate of comorbid mood disorder The rate

found in the Bird et. al. (1988) study was also higher, at 17% comorbidity between

68

affective disorders and ADHD. It would be difficult to speculate at this time

whether these discrepancies are due to differences m definitions between Depressive

and A fective Disorders or if the behaviors necessary for a CART residential or Class

"B" commitment would preclude certain types of vegetative and phobic/anxiety

disorders which were included in the Bird and Biederman studies

Prior study rates of ADHD- comorbid with Psychotic Disorders were

subsumed by the study group of multiply diagnosed Although there was an

incidence of multiple diagnoses of 17.70% in the total population, this can be

explained by the comorbidity of ADID and other diagnoses, or of multiple diagnoses

in the non-ADHD population. The rate of multiple diagnoses plus ADHD was only

5 30%. The incidence of multiple diagnoses plus ADHD did not show Multiplex

Developmental Disorder to be significant to this population at the time of the study as

hypothesized by Barkley (1990). It was interesting to note an absence of MDD

population among the ADHD group in the Private Residential School as this would

be a population considered "at risk" for MDD features. This apparent absence of

MDD may be due to differences in diagnostic approaches since pre-existing medical

records were used in this study rather than any standard testing battery.

Certain outliers bear mentioning at this juncture. There were six unclassified

students at the Hospilal program. OF these, four were subsequently classified as

Emotionally Disturbed. Further, there were eight students at the Residential program

and two at the Hospital program who were diagnosed with developmental delays of

various types, six with mental retardation, severe reading delays or borderline

69

intellectual ability. This population would represent an area for fiture, more in-depth

research involving educationally handicapping conditions in in patient settings and

way in fact comprise the missing MDD population. Another outlier is the single

student in the study who was diagnosed with ADHD without psychiatric comorbidity.

He was placed at the Hospital program and presented with ADHD, Educational

Classification and Tourette's syndrome and presents with such a severe degree of

hyperactivity, impulsiviry and behavioral symptomology that his history includes

three prior long-term m-patent hospitalizations

The final important comparison is between the current study and the in-

patient study cohorts studied by Epstein et al (1991) and Woolston et. al.(1988).

The Epstein study was more concerned with agreement of diagnostic techniques than

incidence rates. Also. there was a very small cohort and little difference in results

between the in-patient cohort and other populations of the study Woolston, however,

found a comorbidiry rate of 51% between behavioral and affective diagnoses among

the two in-patient populations studied. Similarly to the present study, Woolston et.

al. (1988) concluded:

70

The adaptive functioning patterns for both of these groups of

psychiatrically hospitalized children indicated that they demonstrated

significantly poorer socialczatin than commziucation skills; poorer

expressive versus written communication skills; and tended to exhibit

poorer coping skills than play and leiwsre skills. In other words, in

addition to globally delayed adaptive beha7vior, both groups of

children have particular difficulties expressing themselves and coping

with difficnlh social SiituatioFn (p, 712).

The implications of the above quoted research for child study services are

obvious The current research procedure supports the premise of utilizing Child

Study Teams to provide data to plan globally and programmatically as well as to

prepare individual education plans. In analyzing the above metnooed comorbidity

rates, the followng programmatic interventions would be supported.

For the New Jersey State Hospital for Adolescents, with an ADHD population

of approximately 25% (n=10), plans should include one to two classrooms with

teachers who have been specially trained mi ADHD issues and interventions.

Resources such at the LRC annotated subject report on Attention Deficit Disorders

(1994) should be available and related high school worksheets and check lists should

be employed in every subject area. Simply knowing the rate of comorbid ADHD for

this facility would not be sufficient Monitoring the teaching staff for the effects of

71

stresses particular to daily interactions with these populations would be supported by

Biedermnan et. al. (1991) and Biederman et. al. (1992)

The Private Residential School has more issues regarding comorbLd ADHD

and a signi fcantly higher rate of comorbidity of approximately 50% If the research

had counted specific behaviors related to ADHD in the areas or impulsivity,

distractibility and hyperactivity, there may have been an even greater mcidence noted.

For this program, it is recommended that all teachers be trained in classroom

interventions effective with a eomorbid ADHD population. Resources such as the

"Prevention, Teaching and Responding" best practices manual (Hamilton, et. al.,

1994) should be consulted regularly in advance of curricular decisions and m

preparing lesson plans in light of the population configuration.

IMPLICATIONS FOR FUTURE RESEARCH:

ADHD and comorbidity should be studied further. This was a common theme

mn all of the research studies mentioned above One of the biggest problems in

establishing rates of occurrence was the diagnostic overlap between behaviors related

to ADHD and behaviors related to commonly comorbid conditions such as Conduct

Disorder, Oppositional Defiant Disorder, Depressive Disorders, and Psychoses.

Specific Learning Disabilities may promote the development of ADHD like behaviors

as a response to the emotional stresses of being in the classroom over time The

72

issue of 'masking" of symptoms between ADHD and other affective disorders has

not been thoroughly addressed by the research community although it seems to have

gone out of fashion as an explanation of behavioral syndromes since the early 1980's

Further study of the differences between in-patent and out-patient comorbid

populations would be strongly indicated by the above research review. Studies of the

effect of behavioral interventions upon specific restrictive setting classrooms is also

indicated as the above study comprised a needs analysis, not an intervention strategy.

A repeat of the above study with independently applied batteries of diagnostic tests

and procedures rather than acceptance of pror diagnoses would be useful to

corroborate the findings in a more scientifically stringent manner,

The current research did not suggest any explanation for the discrepancy in

rates of comorbid ADHD between the predominantly adolescent Hospital population

and the mixed adolescent and pre-adolescent Residential population. It may be

speculated that some of the reduction of incidence from 51.41% to 25.60%

respectively may be a function of age. Barkley (1990) and other researchers have

mentioned a cut-off in effectiveness of methyphenidate at approximately the age of

13 for some of the population previously diagnosed with AD-ID (40%). These

findings suggest further research in this area. Another subject for further research is

whether or not the behavioral symptoms of ADH-D may have been 'masked" or

overshadowed by more dangerous behaviors such as suicidal, homicidal, aggressive

acting out or self mutilatig behaviors which led to the Psychiatric commitment

Further refinement of our definition of Multiplex Developmental Disorder as it

occurs among in-pattlet populations is also indicated.

Knowledge of their specific population configurations has been demonstrated

to have significaoce for both of the above programs with the potential to effect every

aspect of educational planning. As this high degree of program-specific data was

Sgahered and processed i an ex post facto study, it strongly supports the suitability of

child study teams as a resource for similar population studies. In terms of best

practice, the creation of local population constructs to increase the validity of test

protocols is recommended by Anastasi (1988) in a number of validation contexts.

These population profiles should be considered more frequently as appropriate uses

for Child Study Team practitioners.

The National Agenda for Achieving Better Results For Children and Youth

With Senous Emotional Disturbance (1990) is being considered for national

implementation as part of the Goals 2000 initiative. The following are seven

interdependent strategic targets for the initiative (1990, p. 21).

r Strengthen School and Commnmity Capacity

r Value and Address Diversity

* Collaborate With Families

* Promote Appropriate Assessment

a Provide Ongoing Skill Development and Support

* Create Comprehensive and Collaborative Systems

74

The type of research demonstrated by this thesis will be essential to target the

appropriate interventions directed to the above goals as well as to provide baselines

and intermediate measures of progress targeted to the specific in-patient populations

and should be encouraged.

75

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INDEX OF TABLES AND FIGURES

TABLE£FIGUURE

Table 2.1 ..............................................

Table 4.1 ............. ..... .. ^...... . . . ............

Table 42 .............................................................................................

Table 4,3 .,,, ................ .... --....-. .-.........

Table 4.4 .........................................

Table 4.5 ....--................ ....... ....... ......... ...............

Figure 4.1 ............................ ...................

Figure 4.2 .............................. ..........

79

PAGE

18

54

54

55

56

57

58

59

APPENDIX A

FIGURES

.~ " ; % i i;.

rP j~ 1

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I' ~ :it. .. '.' ifP'.,, '~ .p..~.~~. p.. ..

I /r 4 1OI N.i

' .i'h~.i'i ii:11 ~j il~~~~~~~~~~~~~~~~11

ADHD

.J

Figure 4 1.

m ... 1~ 4Figure4.1A

piLi s '.: t : ,''' :1 ' e: C_:1:|

C 0 :1 . I ;;it.il

.l,,lbj-^\ fiI -Me:!! h

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Figure 4 1B Figure 4 1C

11'~~~~~~~~~~~~~~~~~~.....'1''> 44~~~~~~~~~7"j i7

41 p 4 5 , 4 )l,

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i77-IMEFWUM E~ p~itim i>4'7'p4 41

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CLASSE~~~~~ ' 2i iN a 3§R t~~bON%~C ( I D' 'P ih" ; Pf F' ' : : ::: :

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t S k 3 0? in3 >~ii e e : ^ fr^ D 0> !|" ^i^ i ̂ ii S i-: Eff;iiii > M^ ^ A i~~ Ai, 1 ,.iZ ! t.* f i.i ^^ i~l iilt A:^^, F'ii i i . , ii, ir :ss::' i ...

E *RES Aj HDI j

Figure 4.2.

Figure 4,2A

Figure 4.2B Figure 4 2C

APPENDIX B

DATA

10-11-94.XLS

CASE AXIS IA AXIS IB AXIS 1C AXIS IA AXl 111 ADHD CLASS1 SCHOOL1001 312.90 317.00 _315.31 NO MH FIES1005 309.40 NO ED RES1008 298.90 NO ED RES1010 31381 301.70 NO ED RES1013 298.90 NO EDIPI RES1014 298.90 _ N0 ED RES1015 312.34 300.40 NO ED RES1016 31290 9 _______NO ED RES1021 298.90_ _ NO ED RES1028 296.70 _NO MH RES1030 300.40 308.40 NO ED RES1033 312.90 301.70 315.90 NO ED RES1034 312.90 312.33 _ 311.00 NO ED RES1035 309.40 _ NO ED RES1036 298.90 _ _NO ED RES1039 313.81 315.90 _ NO P RES1043 313.81 NO MH RES1044 313$.81 _NO ED RES1046 298.90 NO ED RES1046 309.40 317.00 NO ED/EM RES1047 312.90 NO ED RES1048 296.34 __NO ED RES1052 312.90 315.39 NO ED RES1054 313.81 NO ED RES105 295.95 NO MH RES1062 298.90 NO ED RES1083 296.30 __NO ED RES1064 298.90 V71.02 NO ED RES1065 309.40 31590 NO ED RES1066 313.81 NO ED RES1068 312.90 .__V71.02 NO ED RES1070 312.90 V71.02 NO ED RES1071 300.40 NO ED RES1072 296.90 _ _NO ED RES1073 812.90 'V71 02 315.90 NO ED RES

074 298.90 NO ED RES036 296.70 _ _301.83__ NO ED HOSP

3081 309.89 312.39 __301.83 NO fl HOSP091 298.90 305.90 311 00 NO ED HOSP

3127 312.39 300.40 309.89 301.90 NO Nl HOSP3134 296.34_ NO ED HOSP

145 295.40 NO ED HOSP3146 296.70 NO ED HOSP3149 298.80 305.90 NO ED HOSP3150 311.00 312.39 312.90 NO OD/PI HOSP3151 309.g9 298.90 315.90 NO P HOSP3156 298.90 295.95 __NO P1 HOSP

Page 1

10-11-94 XLS

CA lAXIS IJA AXIS It AXiS IC AXIS IA AXIS 1 APHD CILASSI SCHOOL3157 295.40 N__O ED HOSP3158 311.00 301 84 _ _NO ED HOSP3159 296.34 301.83 _ NO REG HOSP

3161 295 70 __ NO ED HOSP3162 312.34 00.02 312.39 __NO ED HOSP3163 309.89 301.20 NO PI HOSP3164 298.90 296,70 309.89 301.22 __ NO ED HOSP3165 296.70 312.90 305.90 NO REG HOSP3166 312.39 311.00 301.83 NO EDIPI HOSP3163 309 9 __NO REG HOSP3169 296.30 301.83 _NO REG HOSP3170 309.89 311.00 301 .83 NO ED HOSP3171 311.00 312.39 NO ED HOSP3172 30989 301.83 NO REG HOSP3176 309.89 315.90 NO REG HOSP3176 312.34 310.10 317.00 NO ED HOSP

177 312.39 S0040 317.00 NO NI HOSP3178 312.34 296.70 _15.90 NO ED HOSP1002 314.01 YES MH RES1003 314 01 ___ 313.81 YES ED RES1004 312.90 V71.02 YES ED RES1006 314.01 312.90 313.81 YES MH RES1007 314.01 313.81 YES MH RES1009 314.01 312.34 315.90 YES ED RES1011 314.01 313.81 YES ED RES1012 314.01 312.90 YES ED RES1017 314.01 312.90 __ YES ED RES1018 314.01 3_12.90 _YYES ED RES1019 31401 312.90 315.90 _YES ED RES1020 312.90 314.01 V71.02 YES ED RES1022 314.01 313.81 315.31 YES MH RES

1023 314 01 __YES ED/NI RES1024 314.01 309.40 _YES ED RES1025 312.90 314.01 V71.02 YES ED RES1026 31401 315.90 YES ED RES1027 29.70 314.01 YES ED RES1029 314.01 30940 YES ED RES1031 314.01 29B.90 YEYS ED RES1032 314,01 313.81 YES ED RES

1037 298.90 314.01 315.90 315.31 YES NI RES1038 314.01 298.90 YES ED RES1040 296.70 314.01 YES ED RES1041 314.01 813.81 YES ED FES1042 314.01 298.90 YES MH RES1049 314.01 _ 298.90 YE$ ES D RES1050 314.01 309.40 YES ED ES1051 314.01 313 81 _YES ED RES

Page 2

10-11-94.XLS

CASE AXIS IA AXIS 1 AXIS 1C AXIS iA AXIS IIB ADHD CLASSI SHOOL1053 314.01 298.90 315.90 YES MH RES1055 314,01 _09.89 YES ED RES1056 314.01 _312.90 YES ED RES1057 314.01 312 34 YES ED RES1058 314.01 300.40 YES ED RES1080 314.01 __YES ED RES1061 314.01 309.40 YES MH RES1067 314.01 313.81 __YES ED RES1069 314.01 312.90 YES ED RES3063 310.10 298.90 301.83 _YES ED HOSP123 309.89 312.39 315.90 YES ED HOSP

3124 9&.90 312.90 314.01 _YES PIUED HOSP3132 314.01 312.34 309.89 YES ED HOSP3133 31.81 309.89 311 00 314.01 YES ED HOSP138 314.01 310.10 298.90 315.90 305.00 YES ED HOSP

3160 312.34 311.00 314.01 315.90 YES ED HOSP3167 296.30 312.39 309.89 315.90 YES PILED HOSP3174 296.70 314.01 315,90 _YES ED HOSP3179 304.80 307.23 314.01 YES PIIED ABCTC

Page 3